Complex PTSD: Understanding the Hidden Wounds of Repeated Trauma

What Is Complex PTSD?

Trauma does not always end when the traumatic event is over. For some individuals, the emotional and psychological effects of prolonged abuse, neglect, violence, or repeated traumatic experiences can persist for years—even decades.

While many people are familiar with post-traumatic stress disorder (PTSD), fewer understand a related condition known as Complex Post-Traumatic Stress Disorder (C-PTSD).

Complex PTSD can affect how individuals regulate their emotions, view themselves, establish relationships, and respond to everyday stress. People living with C-PTSD may experience overwhelming shame, emotional instability, chronic anxiety, difficulties trusting others, and a persistent feeling of being unsafe—even when no immediate danger exists.

Complex PTSD is particularly associated with repeated or prolonged interpersonal trauma, especially when escaping the traumatic situation is difficult or impossible.

Experiences that may contribute to complex PTSD include:

• Childhood physical, emotional, or sexual abuse
• Prolonged domestic violence
• Chronic childhood neglect
• Human trafficking
• Captivity or torture
• Repeated exposure to violence
• Prolonged emotional or psychological abuse

However, experiencing these events does not automatically mean someone will develop complex PTSD. Individuals respond to trauma differently depending on biological, psychological, developmental, and environmental factors.

According to a 2025 clinical review published in The BMJ, complex PTSD includes the defining symptoms of PTSD along with additional difficulties involving emotional regulation, self-perception, and interpersonal relationships.

The World Health Organization recognizes C-PTSD as a distinct diagnosis in the International Classification of Diseases, 11th Revision (ICD-11). However, the American Psychiatric Association's DSM-5-TR, commonly used in the United States, does not currently recognize C-PTSD as a separate diagnosis.

What Are the Symptoms of Complex PTSD?

Complex PTSD involves six major symptom domains, divided into two groups.

1. Re-experiencing Traumatic Events

Individuals may experience vivid flashbacks, recurring nightmares, or intrusive memories in which past trauma feels as though it is happening again.

2. Avoidance of Traumatic Reminders

People may avoid certain places, conversations, individuals, emotions, or situations that remind them of traumatic experiences.

3. Persistent Sense of Threat

Hypervigilance, exaggerated startle responses, irritability, difficulty relaxing, and feeling constantly on guard are common.

4. Emotional Dysregulation

Individuals may struggle with intense emotional reactions, anger, sadness, emotional numbness, or difficulty calming themselves following stressful events.

5. Negative Self-Concept

Persistent shame, guilt, worthlessness, feelings of failure, and deeply negative beliefs about oneself may develop.

6. Difficulties Maintaining Relationships

Problems with trust, emotional intimacy, attachment, interpersonal boundaries, and maintaining meaningful relationships may occur.

The last three symptom domains are known as disturbances in self-organization (DSO). These are particularly important in distinguishing C-PTSD from PTSD under ICD-11 diagnostic criteria.

Research examining diagnostic accuracy emphasizes the importance of recognizing these additional symptom clusters rather than focusing exclusively on flashbacks and avoidance. See Kleva and colleagues, Journal of Affective Disorders (2024).

How Is Complex PTSD Diagnosed?

Complex PTSD cannot be diagnosed through a single blood test, brain scan, or brief questionnaire.

A comprehensive psychiatric evaluation is necessary to assess trauma exposure, symptom patterns, functional impairment, and possible coexisting psychiatric disorders.

An evaluation may include:

• A detailed trauma and psychiatric history
• Assessment of PTSD symptoms
• Evaluation of emotional regulation difficulties
• Assessment of interpersonal and relationship difficulties
• Screening for depression, anxiety, and dissociation
• Evaluation for coexisting psychiatric conditions
• Assessment of safety and suicide risk

One commonly used assessment instrument is the International Trauma Questionnaire (ITQ), developed to assess ICD-11 PTSD and complex PTSD symptoms.

The clinician must also consider whether symptoms are better explained by other conditions, including bipolar disorder, borderline personality disorder, major depressive disorder, anxiety disorders, dissociative disorders, or substance-related conditions.

An important distinction is that complex PTSD and borderline personality disorder are not interchangeable diagnoses, even though emotional instability and relationship difficulties can occur in both.

The 2025 BMJ review on diagnosis and management emphasizes the importance of comprehensive, individualized psychiatric evaluation.

Does Complex PTSD Affect Women More Than Men?

Although conventional PTSD is often diagnosed more frequently in women, recent research suggests that the relationship between biological sex, gender, and complex PTSD may be different.

A 2025 systematic review and meta-analysis published in Psychiatry Research examined 167 studies involving 138,681 participants.

Researchers estimated an overall pooled C-PTSD prevalence of approximately 6.2% and found no statistically significant overall gender difference in prevalence.

Similarly, a 2024 systematic review by Lonnen and Paskell, published in the European Journal of Psychotraumatology, evaluated 12 studies examining sex and gender differences in complex PTSD.

Of the nine studies reporting prevalence, eight found no meaningful sex or gender differences, while one identified higher diagnostic rates among women.

These findings challenge the assumption that complex PTSD is primarily a disorder affecting women.

Both men and women can develop C-PTSD, and differences in how symptoms appear are often shaped by the type, timing, and duration of trauma rather than sex alone.

How Can Turned Leaf Psychiatry Help?

At Turned Leaf Psychiatry, Stephen P. Sweeney, PMHNP-BC, provides comprehensive psychiatric evaluations and individualized, evidence-based treatment for trauma-related conditions, including complex PTSD. Care is compassionate, Christian centered, and integrated with therapy and other supports.

If you recognize these symptoms in yourself or a loved one, request an appointment or call (601) 494-5503. Our office is located at 199 Charmant Place, Suite 1, Ridgeland, MS 39157.

If you are in crisis or thinking about suicide, call or text 988, or call 911 in an emergency.

This article is for educational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment.